Elsevier

Gynecologic Oncology

Volume 123, Issue 2, November 2011, Pages 236-240
Gynecologic Oncology

Preoperative staging of cervical cancer: Is 18-FDG-PET/CT really effective in patients with early stage disease?

https://doi.org/10.1016/j.ygyno.2011.07.096Get rights and content

Abstract

Objective

Nodal status is one of the most important findings in patients with early-stage cervical cancer that requires post-surgical adjuvant therapies and influences prognosis of patients. The purpose of this study was to determine the diagnostic accuracy of 18F-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (18F-FDG-PET/CT) in the detection of nodal metastases.

Methods

From 2004 to 2010 women with Ib1–IIa < 4 cm cervical cancer underwent 18F-FDG-PET/CT followed by radical hysterectomy and pelvic lymphadenectomy in our institution. 18F-FDG-PET/CT images were analyzed and histopathological findings served as the reference standard. Diagnostic performance of 18F-FDG-PET/CT in nodal disease detection was reported in terms of accuracy value. A sub analysis of women with tumor diameter < 2 cm (group 1) or 2–4 cm (group 2) was performed in order to verify the efficacy of 18F-FDG-PET/CT in each group.

Results

One hundred fifty-nine women were enrolled. 65% had squamous histotype and 51% had grade 3 disease. Median number of nodes dissected was 29 (range 11–61). 28/159 women (18%) showed nodal metastases. Overall patient-based sensitivity, specificity, positive and negative predictive value of 18F-FDG-PET/CT for detection of nodal disease were 32.1%, 96.9%, 69.2%and 87.0% respectively.

Among the 97 (61%) women included in group 1, 8 had nodal metastases (8.2%) and 2 was discovered through 18F-FDG-PET/CT (25%), while 20/62 women of the group 2 (32.3%) had nodal involvement, of which 7 (35%) was detected by 18F-FDG-PET/CT.

Conclusions

This study showed that 18F-FDG-PET/CT had low sensitivity and had a minimal clinical impact in the pretreatment planning of stage Ib1–IIa < 4 cm cervical cancer.

Highlights

► Prospective evaluation of PET/CT in lymph node staging in early stage Ib1–IIa cervical cancer. ► Low sensitivity and accuracy. ► PET/CT scan has a limited benefit as pretreatment imaging technique.

Introduction

Uterine cervical carcinoma is the second most common cancer diagnosed in women worldwide [1].

Early stage disease can either be treated with radical hysterectomy, pelvic lymphadenectomy or postsurgical adjuvant therapies according to risk factors or definitive radiotherapy, with comparable cure rates [2].

Lymph node status is one of the most powerful prognostic factors in determining the administration of adjuvant therapies in surgically treated patients, and influencing survival rate of patients with early-stage cervical cancer [2], [3], [4], [5], [6], [7], [8].

The identification of pelvic and aortic nodal metastases has a fundamental role in clinical management of cervical cancer patients, as it guides physicians in choosing the most appropriated treatment strategy. 18F-FDG-PET/CT scanners, which combine functional information from positron emission tomography (PET) with anatomical information from computed tomography (CT), have been evaluated over the last years as an innovative non invasive procedure in the pretreatment staging and in defining response to primary therapy or during follow up in gynecologic cancers [9], [10], [11], [12]. In cervical cancer, 18F-FDG-PET and 18F-FDG-PET/CT have been studied to evaluate the response and to diagnose the local recurrence of the disease after chemoradiation therapy, or to detect pelvic and aortic nodal metastases, especially in locally advanced cancer, in order to better define the radiation field [11], [13], [14], [15], [16], [17].

The purpose of this prospective study was to define the role of 18F-FDG-PET/CT in pelvic nodal assessment in a large series of patients with early stage cervical cancer treated in the same institution.

Section snippets

Population and study design

Patients with histologically proven (biopsy or conization) stage Ib1–IIa < 4 cm cervical carcinoma were evaluated for this study. All consecutive patients who met the stage inclusion criteria, underwent 18F-FDG PET/CT imaging at San Raffaele Hospital (HSR), Milan between January 2004 and December 2005 and at San Gerardo Hospital (HSG), Monza, Italy from January 2006 to December 2010. All patients suitable for a surgical treatment underwent surgery at the gynecologic oncology department of San

Patient characteristics and histopathologic findings

From January 2004 to December 2010, twenty-nine women with stage Ib1–IIa < 4 cm diameter cervical cancer treated in our institution did not undergo surgical treatment and were treated with external beam radiotherapy plus brachytherapy with or without concomitant chemotherapy, and were excluded from the analysis. In particular, 16 of these women underwent 18F-FDG-PET/CT which suggested the presence of pelvic node metastasis in 4 patients (25%).

Nineteen women were furthermore excluded because they

Discussion

Cervical cancer treatment is determined by FIGO stage of the disease. Locally advanced stage tumors (IB2-IVA) are usually treated with chemoradiation or, in some countries, with radical surgery after a neoadjuvant chemotherapy, while treatment of early stage IA2-IIA (< 4 cm) disease is based on surgery, including radical hysterectomy and pelvic lymphadenectomy, with adjuvant therapies in presence of pathologic risk factors, or definitive radiotherapy with or without concomitant chemotherapy [2],

Conflict of interest statement

The authors declare that there are no conflicts of interest.

References (50)

  • J.R. Van Nagell et al.

    The staging of cervical cancer: inevitable discrepancies between clinical staging and pathologic findings

    Am J Obstet Gynecol

    (1971)
  • H. Noguchi et al.

    Pelvic lymph node metastasis of uterine cervical cancer

    Gynecol Oncol

    (1987)
  • P. Benedetti-Panici et al.

    Lymphatic spread of cervical cancer: an anatomical and pathological study based on 225 radical hysterectomies with systematic pelvic and aortic lymphadenectomy

    Gynecol Oncol

    (Jul 1996)
  • J.M. Hawnaur et al.

    Staging, volume estimation and assessment of nodal status in carcinoma of the cervix: comparison of magnetic resonance imaging with surgical findings

    Clin Radiol

    (Jul 1994)
  • K. Matsukuma et al.

    Preoperative CT study of lymph nodes in cervical cancer: its correlation with histological findings

    Gynecol Oncol

    (1989)
  • T. Belhocine et al.

    Contribution of whole-body 18FDG PET imaging in the management of cervical cancer

    Gynecol Oncol

    (Oct 2002)
  • H.H. Chung et al.

    Role of magnetic resonance imaging and positron emission tomography/computed tomography in preoperative lymph node detection of uterine cervical cancer

    Am J Obstet Gynecol

    (Aug 2010)
  • L. Yu et al.

    Evaluation of 18F-FDG PET/CT in early-stage cervical carcinoma

    Am J Med Sci

    (Feb 2011)
  • A. Amit et al.

    The role of hybrid PET/CT in the evaluation of patients with cervical cancer

    Gynecol Oncol

    (Jan 2006)
  • A. Loft et al.

    The diagnostic value of PET/CT scanning in patients with cervical cancer: a prospective study

    Gynecol Oncol

    (Jul 2007)
  • D.M. Parkin et al.

    Global cancer statistics, 2002

    CA Cancer J Clin

    (2005)
  • C.H. Lai et al.

    Preoperative prognostic variables and the impact of postoperative adjuvant therapy on the outcomes of stage IB or II cervical carcinoma patients with or without pelvic lymph node metastases: an analysis of 891 cases

    Cancer

    (1999)
  • F. Girardi et al.

    The importance of the histologic processing of pelvic lymph nodes in the treatment of cervical cancer

    Int J Gynecol Cancer

    (1993)
  • Y. Tanaka et al.

    Relationship between lymph node metastases and prognosis in patients irradiated postoperatively for carcinoma of the uterine cervix

    Acta Radiol Oncol

    (1984)
  • P.W. Grigsby

    Role of PET in gynecologic malignancy

    Curr Opin Oncol

    (Sep 21 2009)
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      Previous studies on the accuracy of FDG-PET/CT show wide-ranged sensitivities of 0–68.0% in women with early-stage cervical cancer [29,33,34]. Two studies performed stratified analyses on women with tumors >20 mm; one prospective study presented a sensitivity of 35.0% in 62 women, while Papadia et al. show a sensitivity of 68.0% in 41 women. [29,34]. Papadia et al. retrospectively investigated the use of FDG-PET/CT in combination with SLN mapping and interestingly showed a higher sensitivity than ours.

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